ID: Logan Bramey

DOB: 02/21/1974
45 y/o Caucasian Female
Today’s Date: 10/3/2019

CC: “Cough that won’t go away.”

HPI: Ms. Smith is a 47 y/o Female elementary teacher who present complaining of a
cough that has lasted for 1 week. She had a previous fever of 101 degree that was
treated with Ibuprofen and resolved 3 days ago. She endorses a sore throat, runny
nose, and headaches. Pt states she has tried Mucinex for the cough, with no relief. She
is up to date on influenza vaccination (9/12/2019)
Meds: OTC Ibuprofen
OTC Multivitamin
Allergies: NKDA, no environmental or herbal allergies noted.
PMHx: No surgeries or childhood illnesses noted.
Family History:
Mother: age 67 (living) diagnosed with arthritis.
Social History:
Unchanged from prior visit in August 2019
ROS
General: denies any N/V/D
MSK: denies costochondritis
PE
Reviewed VS with pt: BP: 123/85 HR: 72 RR: 14 T: 98.7 deg W: 140 lbs H: 70” BMI:
20.1
General: Pt is AA0x4, WDWN, dressed appropriately for the season, displays mild
discomfort of right shoulder.
Skin: on inspection there is no rashes, masses, or lesions, skin is warm and dry to the
touch.
Pulmonary: LCTAB with no adventitious lung sounds.
Cardio: normal S1/S2 split with RRR, no m/r/g/c, no peripheral edema present, bilateral
radialis pulses 2+ w/RRR, capillary refill of fingers <3 seconds bilaterally.
MSK: inspection reveals normal muscle tone and bulk of arms bilaterally, palpation
reveals no tenderness over acromion, AC joint, clavicle and greater tuberosity. FROM
with active and resisted shoulder abd/add, internal rotation, and external rotation. Neer’s
impingement test positive for pain on right shoulder, positive pain with active shoulder
abduction and flexion.
Assessment:
Dx:
1) Shoulder impingement syndrome

Plan:
1) Drink plenty of fluids and get plenty of rest.
2) You may drink hot tea and use OTC cough drops as needed for relief of irritated
throat.
3) Use dextromethorphan (Robitussion) OTC as directed on the box to help with
suppression of cough.
4) You may return to work, but please practice good hand hygiene and if necessary
cough in the crease of your elbow.
5) If symptoms do not resolve within 2 weeks or worsen, you may call the clinic for a
f/u visit.
6) Go to ED if you have any symptoms of shortness of breath, chest pain, syncope,
or any other concerning symptoms.
Steven Congress
PA-S